Neurology Flashcards
What are the causes of Virtigo?
Benign paroxysmal positional vertigo. Acute labyrinthitis Meniere's Disease Ototoxicity Acoustic Neuroma Herpes Zoster Traumatic damage Stroke/TIA Migraine Alcohol intoxication
What is BPPV? It’s cause and symptoms?
Condition that causes sudden onset of dizziness associated with head movement.
Causes - usually idiopathic. If young = trauma.
Symptoms - Episodic (10-20 secs) virtigo associated with change of head position. Can be associated with nausea
What features are not associated with BPPV?
Tinnitus
Hearing Loss
Investigations for BPPV?
Family history of RA / back pain - may complicated further examinations
Ear examination
Dix-Hallpike test -
Management of BPPV?
Watch and wait - is this acceptable for the patient?
Epley manoeuvre
Consider Brandt-Daroff exercises. (vestibular rehabilitation)
Betahistine is commonly used (histamine analogue) but not very effective.
What is a Dix-Hallpike test and what is it used for?
Test for BPPV.
Patient sites up, turns head 45o in one direction. Lower patient in this position, make sure head is 30o below horizontal. Observe for rotatory nystagmus and vertigo.
Should be performed, tilting the head both left and right.
What is the Epley Manoeuvre and what is it used for?
Used for the management of BPPV.
With patient lying down, rotate head 90o. Ask patient to turn to that side whilst lying down. Turn head 90o so the head is facing the floor. Ask patient to sit up maintaining the direction of the head tilt. Realign head and flex neck downwards.
What is meniere’s disease and what are the symptoms?
Disorder of the inner ear. Characterised by pressure and dilatation of the endolymphatic system.
Symptoms - recurrent episodes of vertigo (>20 mins each), tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom
a sensation of aural fullness or pressure is now recognised as being common
nystagmus and a positive Romberg test
episodes last minutes to hours
typically symptoms are unilateral but bilateral symptoms may develop after a number of years
What is the classic triad of meniere’s disease?
Vertigo (recurrent)
Tinnitus
Fluctuating hear loss
Usually unilateral
Investigations for meniere’s disease?
ENT assessment to confirm diagnosis.
Refer to audiology
Admit if symptoms severe - IV labyrinthine sedatives (meclozine, promethazine) and fluids.
Second line - Diazepam or Prochlorperazine.
Betahistine for prevention.
Reassurance. Inform the DVLA.
What is acute labyrinthitis and what are its symptoms?
Also known as vestibular neuonitis.
Vertigo following a viral infection.
Features - Abrupt onset of severe vertigo (recurrent, lasting hours), nausea and vomiting.
Horizonal nystagmus is common.
NO DEAFNESS OR TINNITUS.
What is the treatment of acute labyrinthitis?
Vestibular rehabilitation exercises for those with chronic symptoms.
Buccal or IM prochlorperazine for those with acute severe symptoms.
Less severe = proclorperazine or anti-histamines.
What is acoustic neuroma and what are the symptoms?
Schwannoma from the vestibular nerve (rare tumour of the nervous system).
Growth rate = 1mm/year
Tumours slow growing and often benign
Symptoms - unilateral hearing loss with vertigo occurring later. Progressive = cranial nerves affected -V (absent corneal reflex), VI, IX, X) Raised ICP if advanced. Bilateral = NF2
Acoustic Neuroma treatment.
Refer urgently to ENT.
Surgery, radiotherapy or observation.
Acoustic Neuroma Investigation
ENT referral (Urgent) MRI of cerebellopontine angle is investigation of choice Audiometry is important. (
Syncope differentials
Reflex (vasovagal, situational, carotid sinus hypersensitivity, atypical) Orthostatic hypotension Cardiac syncope (arrhythmia, structural heart disease)
Common examinations for syncope.
Cardiac examination
ECG (including 24h)
Blood pressures (standing up and lying down)
Table tilt test
What is vasovagal syncope, signs, management?
Type of reflex syncope. Most common cause of fainting.
Caused by emotional distress (prolonged standing in heat). Common in young adults/adolescents.
Classic faint.
Benign - reassurance and trigger recognition. Avoid BP lowering agents.
Cardiac syncope. Causes, investigations, management.
Causes - arrhythmias, bradycardia. Can also be tachycardia.
Structural - Hypertrophy, valvular, MI
Others - pulmonary embolism.
Cardio examination ECG 24 hr ECG U&E's, FBC, Ca2+, glucose Echo CT/MRI brain ABG (pulmonary embolism, low CO2 suggests hyperventilation)
How do you classify epilepsy?
Either by seizure types of epilepsy syndrome.
Seizure types - Focal (starts in one place but can spread), generalised (both hemispheres affected).
Epilepsy syndrome - juvenille, Dravets
Focal seizure classifications.
Without impairment of consciousness or with.
Frontal movements - posturing (prolonged extension or flexion of the limbs) or peddling. Motor arrest subtle behavioural changes. Language can be affected as well.
Parietal - sensory disturbances such as tingling, numbness or pain
Can also have motor symptoms (if spread to the pre-central gyrus)
Temporal - automatisms (complex motor phenomena with unconsciousness - lip-smacking, chewing, swallowing)
Deja Vu
Emotional disturbance - tremor, panic anger
Hallucinations - smell, taste sound
Occipital - Visual disturbances (spots, lines, flashes)
General seizure classifications
Tonic-clonic - loss of consciousness, limbs stiffen (tonic), then jerk (clonic)
Absence seizure - begin in childhood, sharp onset and offset, eyelid twitching.
Myoclonic - shock-like contraction of the limbs, without impairment.
Atonic - sudden loss of muscle tone causing falls.
Diagnosis of Epilepsy
All patients with a seizure must be referred to specialist.
Take a thorough examination and establish the type of seizure.
Rule out provoking causes - trauma, stroke, haemorrhage, raised ICP, alcohol or benzodiazepine withdrawal
Metabolic causes - hypoxia, hypernatraemia, hypocalcaemia, hyperglycaemia.
Infection - meningitis
Drugs - cocaine, tryclyclics.
Investigations - Bloods (see for above). ECG. Consider EEG
MRI - structual cause
Drug levels - anti-eplieptic medication
DVLA
Headache differentials
Tension headache Glaucoma Migraine Trigeminal neuralgia Cluster headache Meningitis Sinusitis Head injury (extradural, subdural, subarachnoid)